It's time for Medical Insurance Companies in Oregon to cover Autism Treatment

Autism Health Insurance Reform: ACTION: Support the Insurance Division’s enforcement of autism health insurance laws

Contents:

  • Update on Insurance Division’s bulletin on enforcement of autism health insurance laws
  • ACTION: Tell the Insurance Division you support their bulletins with the Consumer Advocate Organizations’ feedback
  • Request coverage and reimbursement — now

Update on Insurance Division’s bulletin on enforcement of autism health insurance laws

As I described in my last message, the Oregon Insurance Division is working on two bulletins directing all Oregon insurers to comply with state and federal mental health parity laws – and begin providing coverage of Applied Behavior Analysis (ABA) therapy immediately:

“Recent court decisions have brought clarity that coverage for ABA therapy should be required of all insurers,” said Insurance Commissioner Laura Cali….

This bulletin will explain that insurers cannot exclude coverage of ABA therapy for autism from their policies. As with other types of medical services, insurers can make coverage decisions based on whether the therapy is deemed appropriate and medically necessary for an individual patient, but they cannot broadly deny payment for ABA therapy.

This is critically important to all of us – we can sue insurers all we want, and beat them every time in court (we’ve never lost), but without consistent enforcement by the Insurance Division the insurers can simply shrug aside the court orders by making token changes to their contracts and carrying on with a new, equally improper scheme to deny lawfully mandated coverage. In the last few weeks since the AF v Providence decision declared Providence’s exclusion of medically necessary ABA therapy for autism to be in violation of State and Federal law, and the Insurance Commissioner’s announcement (above) that “insurers cannot exclude coverage of ABA therapy for autism from their policies”, insurers have continued to issue improper denials.

The State of Oregon has even issued a new PEBB member handbook for 2015 that includes the exact same “developmental disabilities exclusion” language that U.S. District Court found to violate State and Federal law, and incorporates limitations on ABA therapy that violate the Federal Mental Health Parity and Addiction Equity Act.

Insurance Division action is essential to put the last nails in the coffin of this sort of misconduct.

The Insurance Division has released their draft bulletins for public comment, and they have done a great job (you can find them here). Essentially, they have studied all the improper ways that insurers in Oregon and other states have used to unlawfully deny required coverage, and spelled out in plain language that they are forbidden. This provides a clear warning to insurers – but even more importantly, it provides guidance to the Insurance Division’s regulators about when they are authorized take enforcement action against an insurer.

As you might imagine, the Insurance Industry is not at all happy. They have urged the Insurance Division to abandon attempts to enforce the law, and leave the matter to the courts – where each and every lawsuit on behalf of consumers requires an investment of hundreds of thousands of dollars with minimal financial return. This is especially ironic, given the Insurers’ emphatic pleas to the legislature to preserve their unique exemption from Oregon’s Unlawful Trade Practices Act – the antifraud law – on grounds that the Insurance Division has strong authority to regulate them and that these matters are best resolved by regulators and not judges. Since insurers are exempt from that antifraud law, they face very few consequences in court even in cases of intentional misconduct.

We need to respond to the Insurance Industry’s intense political pressure by writing in support of the Insurance Division’s bulletins.

Over the past few weeks, we have been working with representatives of several autism and mental health advocacy organizations – including Autism Speaks, Autism Society of Oregon, NAMI, Basic Rights Oregon, the Oregon Association for Behavior Analysis, the Center for Autism and Related Disorders, and the Lovaas Institute – to review and provide feedback on the Insurance Division’s bulletins. We think the first drafts are very good, and have provided feedback to clarify and correct a few key issues.

ACTION: Tell the Insurance Division you support their bulletins with the Consumer Advocate Organizations’ feedback

The Insurance Division is accepting public comment on the bulletins through Wednesday, October 8th. Please write to the Insurance Division to express your support for the bulletins – with the revisions proposed by the advocacy community (see link above).

I’ve written a simple draft e-mail below that you can use. If you would like to include a personal statement about your situation, such as the difficulties that you’ve had in getting coverage, or the impact the situation has had on you, please do – but remember that your comments will be posted publicly so you may want to avoid any sensitive details that you don’t want the whole world to see. A very short email simply endorsing the bulletins will be a helpful show of support, even without any additional remarks.

The Insurance Division will post all comments publicly at: http://www.oregon.gov/DCBS/insurance/legal/bulletins/Pages/proposed-bulletin-comments.aspx

Send your comments by e-mail to:

victor.a.garcia@state.or.us; jeannette.holman@state.or.us

Here’s a sample message:

Subject: Public Comment on proposed bulletins 2014-1 (MHP) and 2014-2 (ABA therapy)

Body:

Dear Commissioner Cali,

I’m writing in support of proposed bulletins INS 2014-1 (Mental Health Parity) and 2014-2 (ABA Therapy), and encourage you to adopt the revisions proposed by the Consumer Advocate Organizations.

[Optional – if you wish, you may insert a personal about your situation; see notes above]

Thank you for your work on these important bulletins, and the help that you are providing to insurance consumers in the autism community.

Sincerely,

 

[Your Name Here]

———–

Request coverage and reimbursement — now

I wrote this in the last e-mail, but it bears repeating:   If you have ever paid for ABA therapy, you may possibly be able to get reimbursed for it. Certainly, if you want it now, you should be able to get coverage once the bulletins are finalized:

  • If you are interested in ABA therapy, or are already getting it, contact your doctor and submit a preauthorization request to your insurer. If you are denied coverage, please let me know, and submit a complaint to the Insurance Division.
  • If you have EVER had ABA therapy (at least since 2008), submit a reimbursement request to your insurance company. You will probably be denied, especially if the claim is more than 1 year old, but please let me know, and submit a complaint to the Insurance Division.
  • If you are on a waiting list for ABA therapy, please submit a consumer complaint to the Insurance Division about “network adequacy.” There are several other ABA providers willing to start providing treatment in Oregon – but only if the insurers sign provider network contracts, which they aren’t doing.

If your coverage is through Providence, you should contact the attorneys responsible for the AF v Providence lawsuit, and they may be able to help you. Please contact me and I’ll put you in touch.

———

Sincerely,

 

Paul Terdal

 

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